Textbook Hyperfunction or Something Else: When Can Hoarseness be ALS?

When a patient comes to you with complaints of hoarseness, the first thing you do is probably perform your evaluation. Check. You make sure the patient has been seen by an ENT, and then you perform a videostroboscopy. You'll most likely follow with a behavioral voice evaluation and/or a laryngeal function study. You have an idea in your head of what the diagnosis might be before the patient even steps in the room. Case history can lead you in the right direction,  but sometimes it is important to be aware of all possible causes of symptoms, even the very rare. You patient comes in:

1. The voice is strained, pressed and sounds strangled. Hoarseness is present, as well as a mild hypernasal quality and vocal fry.

2.  The patient has a low pitch, it's lower than normal for gender and age.

3. Voice onset for vowels is difficult, and the patient speaks softer than normal.

Initially, you think there is a strong possibility that the patient has Muscle Tension Dysphonia because of the strain. You want to make sure and rule out Adductor Spasmodic Dysphonia, however. You have your patient count from 80-89 to listen for laryngeal spasms. Your videostroboscopy reveals some vestibular fold hyperfunction paired with hypoadduction of the true vocal folds. Your patient is also complaining of some mild dysphagia.

You're still uncertain of what your diagnosis is. There are just some missing pieces. Something is just not adding up. How can you explain the low pitch and low intensity? It might be MTD, but what if it is something else...

Amytrophic Lateral Sclerosis (ALS) has been all over social media lately with the viral Ice Bucket Challenges. It usually presents with extremity weakness, atrophy, and decreased muscle tone. Sometimes, however, it begins with voice quality changes before anything else. A person can develop a voice that sounds strained, strangled, harsh or breathy. The voice might waver with tremor or have unsteady pitch. A patient might also have some hypernasality to boot. A certain kind of ALS onset, called bulbar (affecting the lower motor neurons), can be the culprit. It affects the lower motor neurons in the brain stem, and your videostroboscopy might show some hypoadduction. A patient with this bulbar onset might show signs of mild dysphagia and dysarthria early on, and quite possibly have hyperfunction of false vocal folds and ventricular compression to compensate for that hypofunction.

So how do you determine if it is ALS? ALS has a very rapid onset time, and within months you start to see the degenerative progression in multiple areas. One case study (to be taken with a grain of salt) showed that after 4 months, with the usual treatment for vocal fold atrophy/bowing, there was no improvement. Dysphagia worsened as well as the dysarthria. So, time might be a deciding factor here.

Knowing that ALS is a possible cause for hyperfunction and hypofunction in the larynx is something to hold in your back pocket. It will not happen often as a diagnosis, but it is worth being aware of. Just treat the symptoms you see, and if your patient's condition gets progressively worse despite intervention, there's a good chance you might be dealing with a progressive neurological disease. You should always refer back to the neurologist if you suspect this component.

But with what type of treatment can help you with this differential diagnosis? For bowing or atrophy of the TVF's, you might find success with Lee Silverman Voice Treatment (LSVT) as it has helped improve individuals suffering from age related bowing or Parkinson's disease. You might try to improve the hyperfunction by trying Lessac-Madsen Resonant Voice Therapy (LMRVT) or Casper-Stone Confidential Flow Therapy (CS-CFT) or a variation of Stone & Casteel's Stretch-and-Flow. With whatever is appropriate for your patient, pay close attention to whether there is benefit, or whether quality worsens despite your best efforts.

 

-ATVC

 

References: Watts, Christopher R, and Martine Vanryckeghem. “Laryngeal Dysfunction in Amyotrophic Lateral Sclerosis: a Review and Case Report.” BMC Ear, Nose, and Throat Disorders 1 (2001): 1. PMC. Web. 10 Jan. 2015.

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Acquire The Fire: Why Do We Care About Motor Learning Theory?

#Researchtues

Featuring Integrated Implicit-Explicit Learning Approach to Voice Therapy by Cari M. Tellis

I wonder to myself all the time how I would train another SLP to be like me. Would I be good at it? Thank goodness I had skilled and patient mentors, because voice therapy is a difficult bear! And the skills you acquire should set a fire in you to save the world, one voice client at a time. You have to listen closely and train yourself to command poor productions as well as target ones. I wonder too, how did I obtain all of my skills at discriminatory listening and skilled productions? Which learning type was I? I wanted to spare you the hairy read of this very thought provoking article, and try to give you the quick and dirty. I had time to peruse this article thoroughly, so here is the scoop.

Don't freak out just yet. I had flashbacks to graduate school cognitive therapy classes and I almost began to have a melt down. Let's begin with Implicit Learning. This is what you pick up on in your unconscious learning abilities. Easy, right? You can think of it as how a child learns communication skills as he or she grows and develops. Babies, Implicit babies. Children demonstrate new receptive and expressive communication skills in new ways literally every day and they did not sit through a powerpoint presentation to do so. Plenty of studies have looked at Implicit Learning and say that skills learned implicitly mean that a person has no conscious memory of learning the skill.

Continue to breathe, do not freak out. Let's discuss Explicit Theory now. This is learning tasks or information after detailed instruction. You must easily be able to demonstrate this newly acquired skill on command. This can be done because you had someone telling you the most optimal way to achieve that target production or skill. Explicit teaching is thought to streamline you to the best possible outcome. Think of every CEU you have ever earned. Now, all of that information was most likely learned explicitly through whatever forum you decided to obtain it from...be it online, classroom instruction, one-on-one training, whatever. Explicit learning is usually the mode of choice for left brained individuals, and this is because it appeals to the organized and supported way to learn new information.

So now that we have defined Implicit and Explicit, there is one more potentially complicated term pair that might get your knickers in a twist: Top-down and bottom-up. Okay, the flashbacks are here again. Bottom-up is where you begin with implicit learning and scaffold to explicit learning. Top-down is the exact opposite. This article suggests that combining both, regardless of which is first, can support all learning avenues and give you the best outcome.

So why do we care about how a person learns new information? Because voice therapy attrition rates (fancy word for drop out) are climbing. With 30% of adults reporting voice issues, 65% of them drop out of voice therapy prior to achieving some sort of positive result. Is this because we as voice therapists aren't appealing to each person's learning type right off the bat? It's worth looking into how well you can identify a person's preferred skill acquisition type because your therapy can then propel the client on the most efficient path.

You don't want to overwhelm or confuse clients in the therapy room. Yes, you know your stuff, but they don't care. They just want to get better. So where do you start? Your run-of-the-mill voice therapy sessions utilize auditory-perceptual, implicit learning to get the job done. This is when you produce a target sound, the one you want the client to mimic, and they produce it exactly. Why do we do this? We hope that eventually after practice and repeating-repeating-repeating, the client will generalize because all toddlers walk eventually. Implicit babies, remember?

This is all well and good, but what about when the client is home and discharged from therapy. Can he or she conjure up the targets again? How will the client know if the targets are correct targets? This is where the importance of explicit learning comes into play. Explicit teaching needs to be completed by a therapist who is well versed in anatomy and how the anatomy functions properly and in error. We can only see so much of our speech mechanism (tongue, lips, teeth etc.) and we are left to depend on feeling, visualizing and hearing the rest. So we create metaphors for our clients. Kittie Verdolini cautions to be careful of over doing the metaphors in the therapy room because although they may facilitate, they may confuse.

So Misericordia University and its Voice Science Laboratory have come up with this 5 step process to combine the best of both learning processes for voice therapy purposes. This is because they feel that your brain works better if you are presented with easy and difficult tasks from day one. This should promote generalization outside the therapy room and cut down on in-therapy frustration.

Step 1 is to teach basic auditory perceptual cues to get the client to produce sounds. Have the client ahh like you, then ask the client assess the production. Based on the answers and production accuracy, you can then decide what the client is stimulable for and use that to guide your therapy technique choices. (Oh, and this is implicitby the way.)

Step 2 is teaching anatomy and physiology for my favorite part of the body. The laryngeal mechanism and how it works can be taught two ways, depending on your learner. Part-whole and whole-Part. (Don't hyperventilate, no flashbacks please.) The part-whole peeps learn specific ahhs, oohs, eeehs, forward resonance, back resonance, etc. and then prefer to piece together how they add up to a target voice quality. The whole-part peeps prefer achieving the desired quality before those specifics are even discussed. Decide which your client is, then go. And don't worry, experts and novice voice clinicians both obtain a similar outcomes for patients when helping them while relying on perceptual measures only. Trust you ears and eyes people. (Step 2 is explicit, in case you were testing yourself, you overachiever you.)

Step 3 is adding gestures. Yes, like your voice teacher did with rainbow phrasing and your own personal arm rainbow. Yes, like you do with your little ones while teaching "sh" and running your hand up your arm. Yes, like you do when describing an exquisite Italian meatball dish your grandmother used to whip up. (Lip pucker optional.) Research shows that using gestures offloads the cognitive mechanism. Maybe the Italians are on to something...

Step 4 is, surprise, letting your clients do the work with your guidance. "Deliberate practice is important to skill learning and improves performance and reduces the potential for practicing improper voice productions." Help your clients generalize by giving them a firm base of implicitly and explicitly learned skills to pull from. Guide their practice so they can generalize in a variety of contexts.

Step 5 is nurturing fully capable clients. They have used top-down, bottom-up, part-whole, whole-part, implicit, explicit, however and whatever. They can troubleshoot their own productions and hopefully help themselves in the future because of the expert knowledge and skills you have given them.

Help decrease attrition! Acquire the fire! This study pulls from much hard work and it is right here at your fingertips to take to the streets....or therapy room...hey, you might givevoice therapy on the streets...I don't know. Anyway, happy Research Tuesday!

-ATVC

 

 

 

References:

Integrated Implicit-Explicit Learning Approach to Voice Therapy. SIG 3 Perspectives on Voice and Voice Disorders, November 2014, Vol. 24, 111-118. doi:10.1044/vvd24.3.111

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

The Theme is Scream: Can You Scream-Sing Properly?

Have you heard those heavy metal screaming bands? They may not be your cup of tea, but you might end up with a lead-singer from this type of genre on caseload someday. These singers growl and grunt on a nightly basis when on tour, so how is the voice not completely wrecked? Screaming is not only hard on some people's ears, it is hard on the vocal folds as well. There is, however, a ray of hope for those suffering from vocal issues as a direct result from their love affair with screaming metal music.

As Melissa Cross explains, proper screaming technique can be taught. She instructs singers to scream properly so they can avoid damage to their vocal folds. These screaming performances night after night will take a toll, so without proper training, she warns, it could end a career. You can scream using your true vocal folds and/or your false vocal folds. Your true folds are more delicate than your false, and they have no nerve endings. They vibrate together about 500 times per second, and can swell with overuse and misuse. This swelling is what causes roughness and hoarseness in the vocal quality, because the true vocal folds can no longer vibrate efficiently with increased weight.

Enter, the false vocal folds, sometimes called vestibular folds. The false folds are located right above the true folds and can vibrate together much like the walls of the throat would vibrate for a laryngectomee with a tracheoesophageal prosthesis. This man has had his voice box and vocal cords removed and is using a hands-free prosthesis to inhale air from his stoma. The air does not exit the way it entered, and is forced up through the throat tissue. That is why he sounds the way he does. This is also different from the electrolarynx. Have you seen that tobacco commercial? The electrolarynx is held against the outside of the neck and sends vibrations through the tissue that can be shaped by your mouth, tongue, teeth and lips to produce words and sentences.

Growling is utilized in mainstream music too, but much more infrequently. Artists like Carrie Underwood and Christina Aguilera both use their false vocal folds to add intensity to some of their phrasing. Here, Carrie growls at 1:23 on "fight" and here Christina does it on "My" at 0:03 and on "touch" at 2:38 here.

Ms. Cross is interesting to me because she is a classically trained voice teacher and she is educating a select population on how to effectively use their mechanism for the sound of choice for their music style. She aims for multiple overtones in the screams she teaches, which I would hope would decrease any resultant hyperfunction from too low or too high of a scream. She warns not to utilize both folds simultaneously, for fear of overuse as well.

There is information that is erroneous out there too. Here is someone saying that the epiglottis is responsible for the growl. Um, no. We have this video, I don't know why she is teaching the student to vibrate his palatal arches, but she is. Perhaps she is trying to eradicate any accidental use of the true vocal folds? But why not educate the student on the whole mechanism? The diagram gives me shivers.

Ms. Cross is due to discuss her techniques on a NATS Chat in February, and I'm very interested to hear what she has to say. Her techniques are unusual, but obviously encourage a balanced vocal subsystem of equal parts air, sound and resonance. Your opera singing vocal teacher might cry blasphemy, but it is all the same mechanism, and I haven't run across anyone else who has taken on this niche. Very cool.

 

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Twang, Twang Into the Room: A Look at an Emerging Therapy Technique

#researchtues and #bangbang

Resonant Voice Therapy might have let you hold its hand in school, but I'm gunna show you how to graduate...haha. I can't get that song off my radio!

When I came across the title to the research article I am featuring for this week's Research Tuesday, I wondered to myself about my own "twang" and how often it probably rises to the surface since I'm from Texas. I treat clients often who have a twang of their own and I smile when it is very apparent because it makes me proud to be a Texan and to call this great state my home.

You all may be familiar with Resonant Voice Therapy and its uses for unloading the vocal mechanism. You may not be familiar at all with "Twang Therapy Techniques." Joanna Lott defines it as, "an aryepiglottic narrowing to create a high intensity vocal quality while maintaining low vocal effort." This is narrowing the aryepiglottic sphincter, as evidenced in this video. I wonder why, however, the therapist/examiner is not demonstrating for the patient. Thoughts?

Still wondering how Twang sounds? Think Lois Griffin from Family Guy. Yanagisawa, Lombard & Steinhauer describe it similar to an oboe, banjo or duck quack. I'm thinking, 'Yeah I already have my patients try enough crazy sounds, what's one more animal sound-a-like?' It turns out, twanging, for lack of a better term (so as not to confuse others with Miley Cyrus and her antics) could really benefit a client in the therapy room.

Twang constricts the vocal tract in a way that clusters formants in an acoustically pleasing way because it complements the resonant frequency of the ear canal. Because it increases the perceived loudness levels for the listener, the client can increase volume without increasing effort. Pretty cool, huh?

And.....drumroll please....another guest appearance of, yes, wait for it..... INERTIVE REACTANCE. This is where the back pressure created by this "tube within a tube" eases the pressure and allows the vocal folds to self-sustain vibratory cycles with no excess effort for the patient or performer. (Just like Straw Phonation!)

But is there a danger of bad production habits? With any therapy technique, you must be knowledgeable about it going badly in order to keep your patients on the right side of the line. Aryepiglottic constriction has been found to be present in every-day vocal production, so it is safely utilized by the general public. Hyperfunction, on the other hand, is any false vocal fold medial constriction and is strictly prohibited because it recruits excess and unnecessary muscular effort to phonate. Make sure you are monitoring the difference carefully when utilizing this in the therapy room.

This can also treat the hypophonic voice, as a study by Lombard and Steinhauer proved in 2007. Vocal fold paralysis or atrophy can lead to a breathy, unsupported vocal quality. After receiving voice therapy sessions using twang intervention, all of the participants were very happy with the finished product and that they were increasing intensity without sacrificing effort or coming across like a country-music singer. I wonder how it would work with tandem with an LSVT approach?

When utilizingthis technique, it is important to know how to distinguish twang-y from nasal-y, as evidenced in this video. He is referencing Jo Estill's twang teaching, and educating on how to utilize your aryepiglottic folds when twanging. He explains about the soft palate movement nicely as well.

More studies are needed to determine the effects of twang therapy, so "get a ride in the engine that could...go..." and twang twang into the research scene!

 

-ATVC

References:

Joanna Lott; The Use of the Twang Technique in Voice Therapy. Perspect Voice Voice Dis 2014;24(3):119-123. doi: 10.1044/vvd24.3.119.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

 

The Right Choice When Treating Transgender Voice

 

Transgender Voice Changes. Those words may be intimidating or "something I read a sentence about in graduate school," but they represent a much needed area of education and support. This is not a matter of agreeing or disagreeing with the transition to the opposite sex, but of helping patients in need. We, as speech-language pathologists, are bound by our code of ethics to maintain a cutting-edge perspective in our area of specialty. Any SLP with a license should be aware of this type of service and what is happening in current events.

Just as we are capable of effectively modifying phonemes in children, we have the skills to modify pitch and resonance in transgender voice intervention. We cannot, however, refuse to treat these patients because of our own beliefs. I may believe feeding tubes are unethical, but I cannot refuse to complete a swallow evaluation and treatment based on how I feel. I have a responsibility to evaluate and treat a person coming to me for help if I possess the skills to improve that person's quality of life. 

Voice sessions are usually one of the first things a client begins after hormone replacement therapy has started. Modifications to frequency, resonance, inflection, gestures and word choice are targeted with great care to avoid tension that would cause vocal damage. Sessions require anywhere from 4-9 months and are much more labor intensive than a surgical procedure. The journey to the opposite sex is different for each client, and sometimes gender fluid clients may have goals for a voice quality that is "in between." Clients are often emotional and full of uncertainty and apprehension about what to do next, so determining which personal pronoun your client prefers is important. Maintaining cultural competence and compassion for this population is vital because like the iceberg of fluency/stuttering, we only see 10% of what exists.  

A question is raised, though, about the ethics of providing services to modify or enhance communication performance. Is gender dysphoria a disorder? The DSM-5 recognizes it as a disorder with a specific diagnosis code, and it is not our place to determine the validity of medical diagnoses. Our scope of practice includes typical and atypical communication in the following areas: resonance, language and voice. It also specifically states that we provide clinical services to modify or enhance communication performance for things like accent modification or transgender voice. Speech treatment helps a person overcome an obstacle, and in our code of ethics, it specifically states we cannot discriminate in the delivery of professional services on the basis of gender, gender identity/gender expression or sexual orientation. We help children use fluency tools to overcome the obstacle of stuttering, we strengthen and re-educate swallow muscles to overcome the obstacle of aspiration, and we help those uncomfortable expressing themselves overcome that obstacle so they can fully express who they are. 

So what about billing? What we can bill for is diagnosis driven, and reimbursement is determined by the patient's individual insurance plan. As long as treatment is appropriate for diagnosis, you can bill for your services. As with any other service denial, appeals can be made, but sometimes the patient is left responsible for the balance. Yahoo news published an article about insurance coverage for transgender sex-reassignment health care. It stated that some Fortune 500 companies were adding coverage for this type of health care for their employees. This includes sex-reassignment surgery (SRS) and hormone therapy as well as some counseling. The coverage, however, is not extended to cosmetic surgery. Voices are used to communicate and they are the first thing others hear when we make a phone call, but at this point in time insurance companies do not consider transgender voice changes medically necessary. 

Voice intervention allows these patients to finalize a missing puzzle piece, check off a box and become more comfortable in their own skin. Transgender clients are just like other speech clients and only wish for the best quality of life. For them, that means voices to reflect who they are on the inside. A speech-language pathologist can make every difference by utilizing his or her unique skill set and experience to help.

Education is the most effective tool we have for helping clients generalize treatment goals, so why aren't we educating ourselves at every opportunity?  If you don't feel competent treating individuals who wish for transgender voice change, you are obligated to seek out and refer the patients to clinicians who do. There is a Facebook group which can help with finding a qualified clinician called "Transgender Voice & Communication." Also, WPATH SOC 7 has included voice and communication in their standards of care. We may encounter transgender patients, students, colleagues or clients, so whether or not we agree or feel comfortable with their lifestyles, we must strive to be culturally sensitive to all populations. 

Portions of this blog were originally published in November 2014 on www.atempovoicecenter.com, but have been updated and modified for this post.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Posted on November 24, 2014 .

Voice Rx: Birth Control, Tylenol and Breath Support?

I was listening to a podcast from NATS (National Association of Teachers of Singing) this week and was surprised when I heard that Dr. Robert Sataloff was being interviewed. He is a special physician because he has his Doctor of Musical Arts in Vocal Performance from Combs College of Music in addition to being an otolaryngologist and a musician, which peaked my interest immediately. I am sure that others know of him already, but this was news to me and it made me excited. I couldn't wait to hear the questions that the NATS group had for him.

This chat was on the subject of performing arts medicine and care of the professional voice. The first question raised was in regards to PMS. I immediately thought back to voice changes that Moya Andrews talked about around "that time of the month" in one of her books. The doctor said to consider avoiding any diuretics or water-shedding pills when you are about to start your period. Why? Because during the pre-menstrual time, the vocal folds are swollen, like other muscles in your body, with a protein-bound edema fluid which will not be expelled by a diuretic. The only thing that taking these pills would do is strip the essential epithelial lubrication on your vocal folds and make them more susceptible to damage from overuse and misuse. The swelling remains until the woman's period has finished. His recommendation for the few days prior to your period beginning? Stay hydrated. I'm thinking, yeah....let's add more fluid to the mix....Mucinex will not compensate for the benefits of hydration, but it might help you thin secretions when they are too thick. You should avoid any bloating pills if you are a professional voice user. He also recommends in some extreme cases that birth control pills can help with avoiding that fluid overload altogether by hormone regulation.

Next he addressed pain killers. Ibuprofen and aspirin were discussed in detail in regards to the effects on the voice, but the consensus was that Tylenol or any acetaminophen was usually safe for the vocal performer. Ibuprofen (Advil and Motrin) thins your blood and puts you at risk for vocal fold bleeding for only about 24 hours. For the time the drug is still in your system, you should be careful not to strain or overuse your voice. Aspirin, he warned, is even more dangerous to the professional voice because its effects last 7-10 days after just popping one pill. It interferes with platelet function, so it increases the bleeding risk for a person. He also says that if your blood vessels are already dilated and delicate (ie you are about to begin a period or are sick with laryngitis or a cold) and then you consume ibuprofen or aspirin, you are at very high risk for hemorrhage of the vocal folds. Old types of birth control pills with high doses of hormones used to cause some consumers to lose part of the upper vocal register and when pills were ceased, the voice returned to normal. New BC pills, though lacking formal studies, don't seem to be having that dramatic of an effect on the voice because they contain much lower amounts of hormones. He warns women to be wary of birth control pills containing androgens (male hormones), as they may lower the pitch of the voice.

He discussed vocal fry with one listener. This is the way a Kardashian speaks, with a low, guttural creak at the end of almost every utterance. We categorize our voices within 3 registers or physiological frequency ranges: modal (normal)-- falsetto (high)-- and fry (lower). For modal register, the vocal fold vibratory cycle contains vocal folds spending an equal amount of time open as they spend closed. Falsetto produces sound with the vocal folds barely touching or not at all. Vocal fry is different. Vocal Fry produces sound with a very long vocal fold contact time. Here, the majority of the sound production time is spent with closed vocal folds. It is this constant contact in combination with the pressing that causes the vocal fold damage and makes this a vocally abusive behavior. Most of the time, Dr. Sataloff says, people are using poor breath support when they utilize the fry register. I know I find myself doing it when I'm lying in bed on the phone or when I'm tired.

When a person presses, he or she is squeezing the muscles of the larynx to make sound instead of letting the breath do the work. He reminds us that most of the time, using vocal fry is abusive to the vocal folds.

He also discussed the importance of diaphragmatic breathing and body awareness to treat MTD or Muscle Tension Dysphonia. He encouraged relaxation awareness to improve outcomes for professional voice users and even gave a "shout out" to Speech-Language Pathologists and singing voice specialists and our important role in treating this disorder in speakers and singers.

This was a nice breath of fresh air about voice and medicine and I am thankful this was shared on a twitter account I follow.

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Straw Phonation Takes Center Stage

Make Straw Phonation fun for your younger voice students. Click Here!

Make Straw Phonation fun for your younger voice students. Click Here!


Try Ellie Elephant for Straw Phonation fun! 

Try Ellie Elephant for Straw Phonation fun! 

A light-hearted look at a Facebook group message that got over 64 comments. The funny group dynamic took it to boozy new heights and with a little science thrown in there, hopefully others learned about inertive reactance since Renee Fleming is already a fan.

I am a member of a classical singer forum on Facebook and never have I witnessed such a long winded comment section on a post until the other day. I wanted to share it with you all because I couldn't help but laugh out loud.

It began innocently enough with someone mentioning a recent master-class given by Renee Fleming. Ms. Fleming had been teaching singers to carry a straw with them at all times to warm up without disturbing others in close proximity with a full-out vocal blast to the ears. The comments began slyly rolling in about how straws should be saved for whiskey drinks, but others were intrigued. "Mind blown!" one said, "Great tip!" said another.

There were those who were confused, "How is it different than humming?" they wondered, "How is this straw supposed to work?" There were those who were gung-ho, "Is there a consensus among us that this works?" and, "Straw business is so hot right now."  (images of Hansel from Zoolander begin to swirl around in my head.) And there were those who were less than amused, "I hope she offered more than that." 

 

Folks were sneaking to fast food joints to grab a straw to try and experience this strange phenomenon and one woman even attempted with a turkey baster, to which her comrades replied that they hoped she removed the rubber part before attempting.

Some were defending this technique as if were their own flesh and blood, "It is not a sick joke! This was actually useful advice." One man even mentioned that a speech pathologist had taught him this trick and that he found it helpful. I smiled a bit there because straw phonation has been a shining star in my bag of tricks because of its ease of use. For easy to use diameters, try these. Narrow diameters produce more occlusive effect, like these. For the more environmentally conscious vocalist, these metal ones are great!

I chimed in with, "Straw phonation is a form of semi-occluded vocal tract exercises. Humming and lip trills and tongue trills and straw phonation are all semi-occluded vocal tract exercises. This allows for the singer to phonate with no excess glottic tension at the level of the vocal cords. It also elongates the vocal tract and narrows it, providing inertive reactance (back pressure) at the vocal cords. The vocal tract actually assists the vocal cords in vibration, easing their load."

One man thanked me for being scientific at this time of the morning and I provided video input from Ingo Titze's YouTube demonstration of straw phonation to aid quelling in any further confusion. The conversation soon turned to things I will not mention here on this blog, but in it somewhere were people mentioning Titze, tools, more alcohol, drunk tenorial overlords, and a woman carrying a straw since '82 and a commenter telling her she better change straws because that one is probably old. Ha.

When I speak to professional voice users about the many ways straw phonation can be used, I usually demonstrate how you can go from singing a line in a song, to straw phonating that line, to singing the line again to help improve your body's ability to reduce tension. You can access some materials for making this interesting and fun here.

Try this complete packet for making straw phonation fun.

Try this complete packet for making straw phonation fun.

 
Characters for your straws!

Characters for your straws!

It helped me immensely to sing back and forth, with and without the straw to improve my own abilities and to cut back on vocal cracking and obtain a more easy and pleasant sound overall. No audience wants to watch a strained singer right? The audience likes to be enveloped in the artistic moment while watching a singer who produces notes and phrases as though it were syrup dripping right off the stage into the onlookers' laps.

Anyway, back to the Facebook hysterics, I tried to verbally explain this all to someone I hoped would find it as funny as I had, and he was not amused. Here's hoping the musician humor can be translated here.

-ATVC

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

A Cure for Stage Fright? Can Blood Pressure Medication Help or Hurt?

In honor of #ResearchTuesday, I have chosen to blog about a study I was given to peruse this past week about a double-blind controlled trial about how stage fright affects the voice. Stage fright is an issue for many performers and public speakers, and has varying degrees of intensity. The study wanted to explore quantifying these effects of stage fright stress on the human voice.

In previous studies, fundamental frequency (your voice's pitch) is the constant here, as it is documented to increase with stress. Conflicting evidence on vocal intensity (loudness) and speaking rate exists, so I guess for some individuals experiencing stage fright, you might get louder with a faster rate of speech or quieter and slower....or a combination....My mind begins to wander back to middle school presentations I had to give. I stood there at the front of the class, shaking and flushed in the face. I can't remember what my voice did, so I'm was interested in the outcome of this study.

Some folks don't like the shaky, sweaty palms, nausea or diarrhea that stage fright brings upon a person...I wonder why? So, they take beta-adrenergic blockers. This is your basic medication to lower the blood pressure by blocking adrenaline and slowing the heart beat, but side effects are a danger.

So this study took individuals and induced stress upon them by putting them in a room with 200 IEP goals to formulate in 1 hour's time. No, I'm kidding. They used cold pressor testing, then gave one group a placebo and one group medication and tested Fo (fundamental frequency), voice onset time, speaking rate, jitter (cycle-to-cycle differences in frequency or pitch), shimmer (cycle-to-cycle differences in amplitude or loudness), and a few other measures. Cold pressor testing is your hand in ice water for one whole minute (aka how one tries to prepare for the pain of child labor...ha. Just keep breathing and imaging yourself on a sunny beach...)

Findings were an increase in blood pressure more in female participants than in male, but both the placebo group and the medication group showed an increase. Jitter increased following medication for stage fright, and speaking rate increased with no medication following the cold water test. I am pretty sure I would have the same reaction if you made me hold my hand in an ice cold glass of water. "Please let me take my hand out now thank you very much yadayadayada....." It would be like truth serum.

It was interesting to me that the researchers hypothesized that the voice parameters measured would all increase in a person with stage fright. They thought the changes in the lungs from the body's reaction to the cold water test would increase the airflow in the throat and therefore increase the vocal fold vibratory speed (making the person's pitch increase). They found that without medication to combat the stress, a person's pitch increased.  

Unfortunately, the only statistically significant finding from this study was that jitter increased after receiving medication for the stress. This means that there is no reason to pop some blood pressure meds before your huge opera debut or that presentation you have to give this week to keep your voice from going all wonky. In fact, this study actually suggests that professional voice users should avoid any medication of this type before singing or speaking because it might be counterproductive, as it increases the noise in your voice.

I guess we will all have to just rely on practice, practice and more practice to keep the "jitters" away during any performance or speaking engagement. Fake it 'till you make it, and by then you will have performed so many times, the stage fright should only come from a ghost light...

-ATVC

 

References:

Beta-Adrenergic Blockade and Voice: A Double-Blind, Placebo-Controlled Trial. Giddens, Cheryl L.; Baron, Kirk W.; Clark, Keith F.; Warde, William D. Journal of Voice , Volume 24 , Issue 4 , 477 - 489.

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Making Functional Aphonia Treatment Functional

Functional aphonia, conversional aphonia, psychogenic aphonia, acute sudden voice loss, hysterical aphonia....They all are names for the same disorder. In school, I learned that functional aphonia was when a person lost his or her voice and couldn't figure out how to speak again despite trying. In clinical experience, I have found that many factors can contribute to functional aphonia, not all clients are "malingerers" and it takes skill, patience and experience to separate these malingerers from those truly in need of voice therapy.

With this diagnosis, many insurance companies deny at the hint of anything functional. They see "functional" and read it as the patient is "choosing" not to speak. It doesn't help that some patients receive secondary gain from this disorder and "milk it for all it is worth."  This may sometimes be the case, but for most functional aphonics, this disorder is something they cannot recover from without intervention. It usually occurs following an illness (such as an upper respiratory infection) or following a traumatic or emotional occurrence. It may even develop as a result of fear.

Before speech therapy was seen as an appropriate intervention technique, psychogenic aphonia was treated in very odd ways. One way was essentially "suffocating" the patient to evoke a vocal cry of alarm. Other treatments included using electricity, grabbing the tongue, water torture or cocaine applied to the laryngeal mucosa. Yikes...None of my therapy techniques include any of these thankfully.

The first functional aphonic patient I ever saw was by observation only. She was a young woman who had a child at home. Being a single mom, she worked at a very demanding job where she had to use her voice all day. She was receiving voice therapy fully paid for by her insurance company, and her job was giving her time off for short term disability. Each time she would come for a session, we made progress and she was able to find a wonderful and resonant target voice. The next time she would come in, the voice would be whispery and diminished again. It made me wonder if she was just using the time off for whatever personal reason, but the struggle in each session to achieve a normal sounding voice was all too real.

A memorable functional aphonia patient I saw was in a hospital where I worked. He had not been intubated, and I spend most of the evaluation trying to figure out if he was faking or not. Malingerers are out there... The more I found out about his family and the emotional trauma of what brought him to the hospital, the more I realized that the trauma itself had changed how this man functioned in every way, including how he spoke. It took 3 sessions before he even made a noise, but through semi-occluded vocal tract exercises with a straw in a cup of water, we were able to bring him into a complete and normal speaking voice in no time.

This population can be difficult to treat because, like most voice cases, no "one" treatment will work all the time. I have compiled a list of tricks and tips to help any SLP treating a functional aphonic achieve that "light bulb" moment.

  1. Bubbles in a cup. Begin with water in a cup, 1/3 of the way full or so. Have the patient place the straw in the water and blow air until bubbles are seen. This gives the patient visual feedback that air is indeed flowing. Next, have the patient begin to hum this way. Sometimes the distraction of the cup, the vibration of the bubbles and the noise made is all that is necessary to get phonation to occur again.
  2. Gargle. If the patient is appropriate and not an aspiration risk (i.e. not bedbound or on a ventilator), get some warm salt water, or plain water to gargle.
  3. Raspberries or tongue trills. These semi-occluded vocal tract exercises are based on the same scientific idea as straw phonation,  but these easy productions may be the key for some patients.
  4. Laughing. Get out your joke book here. Sometimes all that is needed is good old-fashioned joking around. Some YouTube videos can be used as well. I like this old superbowl commercial about herding cats. It's hysterical.
  5. Being silly. Act out some lines from a play in ridiculous accents or at different tempos.
  6. Masking. If you have headphones with some white noise you want to use, great! If you are interested in a more budget friendly and quick trick, crinkle paper towels or plastic next to both ears while having the patient attempt to phonate.
  7. Technology. Use your phone or a small recording device to record the patient making these noises. Sometimes patients will not even believe it is really them in the recording, so videos are the next step here.

Make sure you are utilizing negative practice in your sessions because the quicker the patient regains the ability to reorganize his or her own kinesthetic framework for phonation, the quicker the patient can get back to a normal life.

-ATVC

 

References:

Kollbrunner, Juerg; Menet, Anne-Dorine; Seifert, Eberhard. Psychogenic aphonia: No fixation even after a lengthy period of aphonia. Swiss Med Weekly, 2010,; 140(1-2):12-17.

Stemple, Glaze & Klaben. Clinical Voice Pathology: Theory and Management, Fourth Edition. Plural Publishing, 2010.

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

 

Let's talk Larynx

If you are interested in voice and voice disorders, like me, you may have found that your interest in knowledge of voice anatomy did not peak until you were waist-deep in your graduate studies. Or maybe you have always been doodling posterior cricoarytenoid muscles in the corner of your MEAD spiral notebook pages. (WARNING: the previous link transports you to a very graphic video of an actual larynx...not for the weak) I studied and memorized all the muscle names for each test during school. It one day dawned on me that it was just easier to know the ins and outs of the laryngeal mechanism in order to better understand my craft. But, why didn't this occur to me years earlier? Like, perhaps, when I began singing? Or better yet, when I discovered the left true vocal fold cyst that plagued the beginning of my college vocal performance career.

I have found that the more I know about the larynx and its muscles, the better I am at explaining therapy techniques, lay-man's terms anatomy and vocal fold vibratory dynamics to my patients. This is great because when I first began my experience with voice patients in my internships, I was allowed to provide descriptive verbal anatomy to the patients. Man was I excited. I would practice my "spiel" on the way to and from the clinic. I would wait nervously during each videostroboscopy I was observing until it was my turn to give them the best anatomy lesson of all time!! But, I would get weird looks when I spoke of a thyrohyoid space or healthy looking thyroarytenoids. It was great that I knew the anatomy, but no one cared. They just wanted to understand why the physician had sent them and what magic we were going to prescribe. I had a patient's wife tell me recently that she was so thankful I had taken the time to actually talk to her and her husband about the exam in a way they could understand. I took this pat on the back and thought, "Maybe I finally am able to find a good mix between medical terminology and real-world explanations."

I am always finding a new and better way to explain things, and when one perfect way of describing something finds its way into my brain, I'm sure a few gems from a while back make their way out. It reminds me of a Married With Children Episode I watched a long time ago where Al puts Kelly on a trivia game show,  but for each new thing that she learns, a previously learned fact is forgotten. While I am glad that this is not real life, I went to a continuing education seminar this summer where I was able to take in succinctly presented information on vocal anatomy. While Kelly loses an old fact with each new one learned, I felt that I continued to fine tune my knowledge base and built upon what was already there. (Please visit the voiceboxvalhalla laryngeal anatomy website here. Thank you TCU.) It's a nice change of learning style when you can learn the fun things like pathologies after you already spent the time learning the dry names and functions. (Think late-night graduate study cram sessions where 3am rolls around, you are all batty from red-bull and lack of sleep, quizzing each other as if it were some sick-twisted endless Jeopardy episode.)

The larynx is such an amazing apparatus housing those vocal folds that are, as Ingo Titze says in his book (Fascinations with the Human Voice), "woefully undersized." With our dime sized vocal folds and our 7 inch vocal tract (epilarynx) we are able to completely mesmerize an auditorium full of audience members with no amplification whatsoever. Our larynx is made entirely of muscles and ligaments, with the hyoid as the only bone. Just as I fine tune my explanations, I work on keeping my larynx free from tension. This is a daily learning experience, which can be frustrating at times, but I feel I have a much more efficient practice technique with all the anatomical knowledge I know possess. And if I forget things, I won't be calling Kelly...

 

-ATVC

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

 

Posted on October 13, 2014 .